What is the recommended management for a patient who has already had spontaneous bacterial peritonitis (SBP)?

Management of Patients with Previous Spontaneous Bacterial Peritonitis

Patients who have had a previous episode of spontaneous bacterial peritonitis (SBP) should receive indefinite antibiotic prophylaxis with norfloxacin 400 mg once daily to prevent recurrence. 1

Rationale for Secondary Prophylaxis

Patients who survive an episode of SBP have:

• Approximately 70% recurrence rate at 1 year without prophylaxis 2
• Poor long-term survival (30-50% at 1 year, 25-30% at 2 years) 2
• Significant reduction in SBP recurrence with prophylactic antibiotics (from 68% to 20%) 2

Prophylactic Antibiotic Options

First-line therapy:

• Norfloxacin 400 mg once daily orally 2, 1
  • Most extensively studied and recommended by guidelines
  • Reduces probability of SBP recurrence due to Gram-negative bacteria from 60% to 3% 2

Alternative options:

• Ciprofloxacin 500 mg once daily 1, 3
  • Weekly ciprofloxacin (400 mg) has been studied but daily dosing is preferred 1
• Trimethoprim-sulfamethoxazole 800/160 mg daily 1, 3
  • Similar efficacy to norfloxacin but may have more adverse events 3
• Rifaximin - emerging alternative with potentially:
  • Greater effectiveness than norfloxacin for secondary prophylaxis
  • Fewer adverse events and lower mortality 3

Important Considerations

Monitoring and Follow-up

• Regular assessment for breakthrough infections
• Monitor for signs of antibiotic resistance
• Follow-up paracentesis if symptoms of infection develop

Antibiotic Resistance Concerns

• Long-term quinolone use may lead to resistant infections 2, 1
• Consider discontinuing quinolone prophylaxis if infection with quinolone-resistant bacteria occurs 1
• In areas with high quinolone resistance, alternative antibiotics should be considered

Liver Transplantation

• All patients who recover from SBP should be evaluated for liver transplantation 2, 1
• SBP is a marker of end-stage liver disease with poor prognosis

Additional Management

• Avoid proton pump inhibitors unless clearly indicated (may increase SBP risk) 1
• Consider discontinuing beta-blockers in patients with refractory ascites 1, 4
• Albumin administration during active SBP episodes (1.5 g/kg on day 1 g/kg on day 3) reduces risk of hepatorenal syndrome and improves survival 1

Treatment of Recurrent SBP Episodes

If SBP recurs despite prophylaxis:

1. Obtain ascitic fluid culture and sensitivity testing
2. Start empiric therapy with third-generation cephalosporin (Cefotaxime 2g IV every 8 hours) 1
3. Adjust antibiotics based on culture results
4. Consider alternative antibiotics for nosocomial SBP or treatment failures:
   • Piperacillin-tazobactam 4
   • Amoxicillin/clavulanic acid 2
5. Add albumin (1.5 g/kg at diagnosis, 1 g/kg on day 3) for patients with renal dysfunction or hyperbilirubinemia 1

Duration of Prophylaxis

Prophylaxis should be continued indefinitely until liver transplantation or death, as the risk of recurrence remains high 2, 1. There is insufficient evidence to support discontinuation of prophylaxis even if liver function improves.